Tag Archives: Substance dependence and addictions

Substance Abuse & Addictions

The intersection of childhood trauma and addiction

By Shannon Karl April 13, 2021

Substance dependence leads to persistent negative consequences and the loss of human potential. These consequences often include chronic health problems, dysfunctional family environments, harmful economic impacts and premature death. According to the Centers for Disease Control and Prevention (CDC), 21.2 million individuals in the United States met the criteria for a substance-related disorder in 2018. Deaths from overdose have tripled in less than two decades, with over 70,000 annual drug overdose deaths in 2019, 70% of which resulted from opioids such as morphine and fentanyl.

Substance-related disorders include 10 classes of drugs: alcohol; caffeine; cannabis; hallucinogens; inhalants; opioids; hypnotics, sedatives and anxiolytics; stimulants; tobacco; and other/unknown substances. Exposure to childhood trauma increases one’s risk of addiction across classifications, along with deleterious factors such as physical health and socioeconomic challenges. The Adverse Childhood Experiences (ACE) study, originally conducted by Kaiser Permanente and the CDC from 1995-1997, identified categories of trauma that can occur prior to age 18. These include physical abuse and neglect, emotional abuse and neglect, sexual abuse, and household dysfunction — e.g., mother treated violently, household substance misuse, parental incarceration, parental mental illness, and divorce.

These factors make up the 10 components of the ACEs score, with research supporting higher likelihood of substance-related disorders as exposure to ACEs increases. According to the American Society of Addiction Medicine (ASAM), addiction has biological, psychological, social and spiritual manifestations. Given the deleterious nature of addictive etiology, professional counselors need to be aware of the vulnerability to addiction for those affected by childhood trauma. The intersection of ACEs and addiction holds pervasive negative impact across the life span.

The National Institutes of Health (NIH) asserts that traumatic events can serve as triggers for substance misuse. NIH reported that 38% of high school seniors admitted using an illicit substance in 2019, with marijuana being the most frequent substance utilized. Startlingly, 11.8% of eighth graders reported marijuana use. In addition, 11.7% of high school seniors reported daily nicotine use, and more than half acknowledged using alcohol in the prior year.

Exposure to ACEs can lead to toxic stress and myriad negative consequences, often including lifelong deleterious effects on physical and mental health. The high rates of individuals living with the trauma of ACEs is startling — 61% of individuals have endured at least one ACE, and nearly 25% of individuals report three or more ACEs. There appears to be specific vulnerability to addiction for those who have experienced four or more ACEs. The higher the ACEs score, the greater the negative health impact. More than half of adolescents who live with mental health concerns also have diagnosable substance-related disorders, which underscores the comorbidity of the issue.

Ramifications of ACEs can include addiction, reduced access to education, and vulnerability to sexual exploitation and trafficking. Tobacco and prescription drug use is higher among those with ACEs, and illicit drug use increases more than twofold with each positive ACEs category. Other lifelong instability factors that have been shown to correlate with ACEs are high-risk sexual behaviors, early pregnancy, suicide attempts, sleep disturbance, poor dental health and multiple physical health concerns. Both children and adults with extant mental health issues misuse substances at higher rates.

According to the U.S. Surgeon General, approximately 10% of children live with mental health concerns that rise to a clinical level, with major depressive disorder representing a leading cause of disability in children worldwide. Research supports the strong connection between experiencing adversity during childhood and the ensuing development of addiction. More than two-thirds of children will experience a traumatic event before the age of 16. And with the current pandemic, many children are in homes that are violent or otherwise unsafe. Alarmingly, domestic violence incidents were up 30% in 2020, exposing untold youth to at least one of the ACEs factors.

Treatment needs

Reports regarding heightened clinical levels of anxiety and depression among the general population suggest that stress related to the COVID-19 pandemic affects everyone. Adolescence already represents a critical developmental period for initial onset of mental health and substance-related disorders, so the vulnerability for this demographic is further increased. ACEs are a clear and extant risk factor, with survivors of childhood trauma 15 times more likely to attempt suicide, four times more likely to develop an alcohol-related disorder, and 2.5 times more likely to smoke cigarettes. For survivors of childhood trauma, physical and emotional issues often manifest in adolescence and follow into adulthood.

According to the Substance Abuse and Mental Health Services Administration (SAMHSA), 21.6 million people ages 12 and older needed treatment for substance use in the U.S. in 2019, whereas only approximately 2.6 million people (or slightly more than 12%) received it. These are glaring treatment needs that crosscut demographics. Fentanyl, which can be lethal, is sold in multiple forms on the “street,” continuing the opioid crisis in our country. Tens of thousands of overdose deaths occur per year, with close to 11 million individuals disclosing inappropriate opioid use. Those with ACEs scores higher than 6 were over 1,000 times more likely to use injection drugs.

Chronic substance abuse, a clear risk factor for those exposed to trauma, leads to premature death in alarmingly high numbers. Adolescents with experience of major depressive episodes are more likely to use substances across categories. Coincidingly, 60% of U.S. youth with depression do not receive mental health treatment. Addressing the physical and mental health impact of substance use alone is estimated to cost Americans more than half a trillion dollars annually. The CDC has developed a resource that highlights the available research support for evidence-based prevention of ACEs at cdc.gov/violenceprevention/pdf/preventingACES.pdf. These strategies focus on systemic community-based information and training. Emphasis is also placed on physical health, positive behaviors and supportive environments.

Treatment considerations

Certain populations have increased vulnerability to substance-related disorders due to environmental and genetic factors. This stems from the neurobiological underpinnings of the addictive etiology to the effects of toxic stress. Individuals born into households in which they are exposed to ACEs are more vulnerable to addiction, including process addictions centered on gambling, internet gaming, sex, shopping, work, social media and so on. The use of trauma-informed interventions as early as possible can mitigate deleterious effects and provide protective measures against substance-related and other mental and physical health issues. The CDC offers trainings for those interested in learning more about the prevention of ACES (see vetoviolence.cdc.gov/apps/aces-training/#/#top).

All clients should be evaluated for trauma and addiction history. The concurrence of mental health concerns and substance abuse necessitates treatment that addresses these challenges. Trauma increases the already high comorbidity (upward of 50%) between mental health and substance use diagnoses. Prevention and early intervention services can examine frequency, severity and duration of both the trauma experience and the addiction. The conceptualization of substance use disorders occurring on a continuum (as detailed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders) underscores the importance of prevention and early intervention.

According to the CDC, research shows a propensity to self-medicate with substances to escape or numb negative thoughts and feelings. This suggests that escape from emotional pain triggers the onset of addiction. Women, adolescents and individuals from marginalized populations are most vulnerable to these effects, although anyone can experience childhood trauma and struggle with ensuing addiction.

Clinicians should develop individualized treatment plans and strong referral systems. Genetic and environmental factors work in combination. Thus, we need to gain understanding of these interactive effects. Long-term supports and provision of physical and dental health services can be important for individuals exposed to ACES, especially considering the likelihood of comorbidity with a physical health diagnosis. Increased rates of unemployment and job dissatisfaction represent additional treatment needs.

Relational challenges

Difficulty forming healthy relationships across the life span is a hallmark of surviving childhood adversity. Counseling professionals should thus incorporate strategies for strengthening the family and community. Holistic and family counseling services are beneficial. This includes the provision of psychoeducation and parenting education to address overall life skills, mindfulness and grounding techniques, positive coping strategies and career counseling services. Trauma-focused cognitive behavior therapy (TF-CBT) and multisystemic therapy have shown both short- and long-term benefit with these clients. This can be combined with addiction treatments such as medication-assisted therapy for alcohol or opioid use disorders. The combination of psychoeducation and supportive, trauma-informed and empirically based substance misuse treatments can span the broad needs of this population. All treatment modalities and providers should integrate trauma-informed care.

Early identification and intervention remain important to minimize risks and break deleterious family patterns. Removal of barriers to treatment includes addressing stigma and increasing education for families and communities. Larger scale prevention programs, inclusive of early intervention and postvention services, are indicated. The development of individualized treatment strategies that incorporate trauma-informed interventions are also vital.

Professional counselors are charged to advocate for clients and communities. Screenings in hospitals, clinics and public health facilities can help identify those at risk for substance misuse, especially those with trauma histories, and link them with treatment services. Psychoeducation in schools and community agencies also can improve outreach and access to care. Parenting education classes and life skills trainings are other examples of additive ancillary services. Incarcerated populations are particularly affected, with some studies suggesting a trauma history for nearly the entire population of female inmates. Professional counselors working across these settings should be aware of risk factors and assessment protocols that are culturally competent and inclusive of multiple demographics.

Effective treatments for individuals affected by trauma and addiction can include eye movement desensitization and reprocessing, motivational enhancement therapy, TF-CBT, dialectical behavior therapy, assertive community treatment and family behavior therapy. Psychotropic medication and psychiatric care may be indicated to fully address these complex issues. Some medications may benefit multiple issues (e.g., bupropion for both depression and nicotine dependence). Case management and occupational assistance represent important ancillary services for many clients. Community vouchers can be given for transportation and health care access and allow for possible employment opportunities.

Although thorough and comprehensive treatment can be expensive, it pales in comparison to the economic costs associated with addiction and premature death. With annual estimates for addiction and premature death as high as $740 billion, there is a need for legislation that funds prevention and early intervention services for those affected by trauma exposure and addiction. Given appropriate access to treatment and support, many individuals living with the effects of childhood trauma and addiction can make positive and lasting improvements. The cycle of intergenerational trauma transmission can be broken, providing positive ripple effects for future generations. Individuals can thrive and build healthy families despite their adverse experiences.

Community impact and integrated care

A multitiered approach to looking at immediate issues such as addiction is imperative for individuals exposed to ACEs. Addressing the trauma and providing familial services, social support and preventive measures remains imperative. All professional counselors can emphasize trauma-informed and integrative care. Here are a few simple strategies to tackle this complex issue: Listen with empathy, garner training in trauma-informed practices, develop a strong support and referral system, and provide specialty services to treat the trauma and the addiction. Working together, mental health professionals across disciplines can help survivors of childhood trauma manage life in healthy and productive ways.

The global health pandemic has increased utilization of distance-based services such as telemental health counseling. This modality can provide easier access to services for individuals in rural communities, those with transportation challenges and those with other impediments to treatment.

It remains important to highlight the team approach in addressing the complex issues of childhood trauma, addiction, and the ensuing physical and mental health sequelae. The pervasive nature of this challenge engenders a call to action. Data collection through thorough assessment can inform community decision-making and provide program funding. The Youth Risk Behavior Surveillance System assesses crosscutting data that are available at the local, state and national levels. The National Survey of Children’s Health and the National Crime Victimization Survey also collect data that can inform service provision.

The CDC provides information to promote safe childhood environments and mitigate ACEs exposure and subsequent addiction and disease. On a micro level, professional counselors can focus on parenting and family skills, mentoring, social emotional learning, job skills, and psychoeducation regarding healthy family and interpersonal relationships. On a macro level, professional counselors can promote community connection, mentoring relationships and positive social norms. The critical importance of trauma-informed interventions that are tailored to individual or family circumstances, along with communitywide prevention strategies, are necessary for addressing these serious and prevalent risk factors. These programs can assist children, parents and families beyond mitigation of symptoms.

Family-centered treatments for addiction can address the intergenerational impact. The deficits that come with trauma and addiction are offset by evidence-based interventions and prevention strategies. Access to programs should be available for all levels of care and can be implemented concurrently with ancillary services. Counseling settings can include the home, school or office, and often will involve multiple integrated health care professionals. Given the complexity of the challenge, comprehensive treatment services that include bridging home and school environments and the larger family system remain imperative. The widespread impact of ACEs and their intersection with addiction calls for coordinated care across disciplines. This includes effective tracking and coordination of prevention and intervention services across all aspects of service delivery.

Intergenerational patterns of trauma transmission represent a vicious cycle that professional counselors can help break. Prevention programs must address household dysfunction and adversity, especially considering that ACEs indicate earlier onset of substance consumption. The idea of numbing or comfort-seeking suggests that childhood adversity can lead to addiction through attempts to relieve distress. Quality mental health care can address and ameliorate these maladaptive coping mechanisms. ACEs are also correlated with substance use disorder in older adulthood, underscoring the lifelong ramifications of exposure to childhood trauma.

Addiction treatment facilities partnering with comprehensive and wraparound services can provide targeted interventions to address individual trauma experiences. Tackling the systemic nature of childhood adversity through family services and community advocacy provides additional resources for clients. Professional counselors are an integral part of the overall treatment team. Clients can and do learn new patterns of behavior and positive coping mechanisms that help them live longer, healthier lives. The benefits of prevention and early intervention should not be undervalued. Treatment is ameliorative for trauma and addiction and often engenders positive change in individuals and families.

Professional counselors can assist community members in locating resources and addiction treatment centers across the country via SAMHSA’s national helpline: 800-662-HELP (4357). Viewing survivors of childhood trauma who struggle with addiction or other maladaptive coping mechanisms from a strength-based approach is imperative. These struggles are not born of characterological weakness but result from the impact of lived trauma experiences. Empathy and care go a long way in successful work with trauma survivors.

Conclusion

Abuse, neglect and household dysfunction clearly lead to physical and mental health challenges. The risk of addiction, early death and intergenerational trauma transmission increases with each adverse childhood exposure. Use of alcohol and other illicit substances damages mental and physical health in numerous ways and often intersects with the trauma experience. Vulnerable children and adolescents can and must be protected. Professional counselors play pivotal roles now more than ever.

In 2020, SAMHSA reported a 900% increase in call volume to its disaster distress helpline (800-985-5990). Nearly half of Kaiser Family Foundation respondents asserted that the COVID-19 pandemic is detrimental to their overall mental health. The global health pandemic underscores the burgeoning treatment needs for increasing numbers of vulnerable people. Experiencing trauma in childhood can hinder the individual in all aspects of life. The negative reverberations for families and communities should make this everyone’s issue. Professional counselors hold the potential to help effect positive change for innumerable individuals, families and communities. Let’s make an impact — now and into the future.

 

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Shannon Karl is a professor with the Department of Counseling at Nova Southeastern University, a licensed mental health counselor (supervisor) in Florida, an active member of the American Counseling Association, and a past president of the Association for Spiritual, Ethical and Religious Values in Counseling. Contact her at shannon.karl@nova.edu or linkedin.com/in/shannon-karl-phd.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

DXM: A drug in plain sight

By Emily Weaver, Sharon J. Davis and David Saarnio November 10, 2020

We are writing this article to raise awareness among parents and counselors about a legal and easily accessible drug that is widely used by adolescents to get high: dextromethorphan (DXM). DXM is an ingredient found in certain medications meant to help us get better, so teens frequently abuse this drug without being aware of the potential consequences and dangers. Given the personal insights and experiences we have with the damaging effects of DXM, we are sharing this story in hopes of reaching a larger population and creating more efficient prevention strategies related to teen drug use.

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When co-author Sharon Davis’ son was 17, he began abusing over-the-counter (OTC) cough medicine. He had been using marijuana and K2 (synthetic marijuana) for a few years, but it was Coricidin — a cold medicine marketed as being for people with high blood pressure — that really damaged him.

Sharon’s son became a different person. He had always been a moody kid, but his moodiness turned to anger, mania and psychosis. Over a four-month period, his father and mother took him to the emergency room four times. It wasn’t until he attempted suicide that they really got him the help he needed and found out the full extent of his addiction.

He had been introduced to Coricidin through some friends. Soon he was using 30 pills at a time. Coricidin use led to cocaine use. Cocaine use led to methamphetamine use. Two years later, he is working on recovery, but his mind and mental health will never be the same.

According to the Partnership for Drug-Free Kids, 50% of American teenagers have misused a drug, and drug overdose is the fourth-leading cause of death among teens. Parents, counselors and other adults are well aware of the problem of teen drug use, and the nation’s opioid epidemic has brought the topic of medication misuse to the forefront of public attention. That attention is long overdue. However, that focus also misleads us because other critical concerns are being overlooked.

For example, our society is largely neglecting to talk about the large-scale problem of adolescent misuse of OTC medicine and its potential as a gateway to other drugs. In fact, OTC cough and cold medicine is one of the most popular drugs that youth use to get high. According to the Monitoring the Future survey funded by the National Institute on Drug Abuse, more teens got high from OTC medicine in 2019 than from prescription opioids.

Why OTC?

OTC cough medication is easy for teens to get. In some places, teens can purchase these medications from their local convenience stores. Furthermore, most stores have these medications out on the shelf where they are easy to steal. Teens can also get them from peers and even from parents. Because they don’t necessarily perceive these types of medications as “dangerous,” many parents will store them in an unlocked medicine cabinet, unknowingly allowing their teens easy access to them.

The psychoactive drug in OTC cough and cold medicine is DXM, which falls into a class of drugs known as dissociative hallucinogens. Other drugs in this category include PCP, ketamine and nitrous oxide. The Food and Drug Administration (FDA) approved DXM as a cough suppressant in 1958. It remains legal to buy and use in the U.S. DXM is a safe drug when used as directed, but when used in 10 times or more the recommended dose, it acts as a powerful dissociative, distorting reality. Currently, 85%-90% of OTC cough medications contain this effective antitussive (cough inhibitor). DXM is a synthetic opioid drug, but it activates different opioid receptors in the brain than prescription opioids do.

Teens typically misuse DXM to feel the euphoric, dreamlike experiences and hallucinations it causes. When individuals use DXM to get high, they experience various levels of inebriation, known as plateaus.

There are four plateaus associated with DXM. The first plateau involves mild intoxication and stimulant-like effects. The second plateau features increased intoxication and mild hallucinations. At the third plateau, the user enters a state of altered consciousness with impaired senses and psychosis. The fourth plateau involves a sense of derealization (in which the world appears unreal) and depersonalization (e.g., detachment from the self).

Users describe the higher plateaus as akin to being in other realms or alternate universes. Commonly, users feel an out-of-body sensation, like being transported to another dimension. They lose their sense of self and time. It is common for users to post videos or blogs about their experiences, including what they felt like and what they saw while high. The slang term robo-tripping is how many teens refer to being high on DXM. Slang terms for the drug itself include triple-C’s, robo, skittles, red hots and dex.

Why is DXM problematic?

DXM is a dangerous drug when used outside of therapeutic doses, yet little has been done to curb its misuse among teens. For decades, we have known about the consequences of misusing this drug, including seizures, hyperthermia, tachycardia, psychosis, mania and even death.

The opioid epidemic in this country is a national crisis. It is worthy of public attention and government funding to address. At the same time, DXM misuse among teens is also startling, and yet it is rarely highlighted. This drug is more popular than opioids among young people, and it is legal, inexpensive and easy to get.

It is imperative that prevention efforts and policies address this problem. For example, laws similar to those passed in 2005 that required pharmacies to move the popular methamphetamine-making drug pseudoephedrine behind the counter could make DXM less readily available. Some states already require purchasers of OTC cough and cold medications containing DXM to present an ID proving they are 18 or older. We believe this should become mandatory nationwide and that sellers of these drugs should be held accountable.

Furthermore, mass awareness campaigns targeting parents, teachers, law enforcement and counselors need to remind adults of the dangers of these drugs, whereas prevention programs for children and teens should increase their focus on the dangers of OTC medications. National campaigns and policy changes are called for, but these alone will not likely be enough to cause real change. True prevention efforts require work on multiple levels — from the policymakers in Washington to counselors and parents in local communities. Each of us has a part to play, and each can make a difference.

Where do teens hear about DXM?

In today’s era of prolific internet and social media use, teens have more access to the world than ever before. In past decades, peer pressure to use drugs was a huge concern. It was thought that susceptible teens would be influenced by their peers in the neighborhood and at school. This peer pressure occurred face to face.

Today’s teens still confront in-person peer pressure, but they now also face this pressure virtually. Peer influence can come not just from the local teens at school but from millions of teens across the world online. Many teens access the internet and find out about drugs of abuse, including how to get high on OTC cough and cold medications.

A quick search of popular sites such as YouTube can lead teens to videos that either warn of the dangers of DXM or encourage users to experience the high from it. Unfortunately, many websites include dosing recommendations and “tripping” suggestions for having a better experience of getting high.

For example, Reddit, one of the most popular social media sites around the world, has an estimated 430 million active users. Reddit consists of threads that allow its users to post about certain subjects and topics. These threads are like cybercommunities made up of members who hold similar interests. One of these threads, called “r/DXM,” has more than 31,500 users. This thread allows people a place to describe their DXM highs and the side effects. It also provides advice on how to minimize certain side effects such as nausea.

Other websites and cybercommunities such as Dextroverse.org and the Vaults of Erowid provide teens outlets to post about their DXM highs and get advice from other users on how to use the drug. The site DexCalc.com allows users to enter their weights and get a recommended dose for the “plateau” of high they want to achieve. Although many of these websites claim that their purpose is “harm reduction,” teens typically use these sites for suggestions and advice on the “safest” using pleasures. All of these websites are accessible to teens, and all of them are free to use.

Prevention efforts

Fifteen years ago, the FDA issued warning labels on OTC cough and cold medications aimed at making parents aware of the dangers of medicine abuse by teens. The Stop Medicine Abuse campaign launched nationwide in 2004, but clearly that campaign was not successful. More needs to be done to dissuade youth from abusing OTC drugs.

As counselors, we need to step to the front lines of true preventive efforts. This means that we need to know more about DXM (and other OTC medications), the reasons teens are using it, the ways teens are getting it and the most effective methods to prevent its misuse.

Getting parents involved is a good first step. Parents must know what to look for and how to talk to their teens about OTC drugs. Counselors need to get the message out to parents to be realistic and truthful when educating teens about DXM. Scare tactics do not work for many teens; in fact, they may make teens more curious about experiencing the outcomes for themselves. A better approach for prevention may be for parents, family members and other adults to increase the quality of their connection to and communication with youth.

Research shows that establishing consistent messages against drug misuse and having clear boundaries early on can be among the best prevention efforts for teen drug use. Simple steps, such as hiding medications and taking inventory, can also be effective. Most parents want to trust their teens, but having medications that contain DXM where teens can access them is not wise, and many parents are not aware of the dangers of DXM medications. OTC cough and cold medicine should be as securely stored as opioid prescriptions.

In addition, parents need to know what sites their teens are accessing online. A parallel line of defense involves checking browser histories and having clear rules about what teens can access online. Drug use is a leading cause of death among teens (resulting in more than 5,000 deaths per year according to figures from the National Institute on Drug Abuse). Parents wouldn’t want their teens searching for firearms or lethal poisons online, and no parent should want their teen searching for how to get high from DXM. Parents may not be comfortable with this advice. After all, it may feel like snooping, and teens are likely to resist as well. Even so, what teens access online can be one of the biggest telltale signs of drug use.

Establishing rules for computer/internet usage (e.g., allowing a teen to use the internet for two hours a day after completing homework), installing a firewall and setting locks or passwords for downloads can all be safety measures that contribute to prevention or, when needed, intervention. The earlier that parents establish household internet rules, the better. Proactive planning and putting rules in place before children reach their teen years may prove much easier than trying to establish new rules once teens are in late adolescence.

Talking to teens about drug use is often uncomfortable for parents. Many parents do not know where to begin. Some parents are worried that talking about drugs will increase their children’s curiosity about using. Other parents simply find the topic embarrassing or awkward. As counselors, we need to help parents develop communication skills with their children and teens, but especially starting in middle childhood. Counselors can provide parents with resources for where to find information about drugs of abuse, and we can intervene if a teen has already started using. It is almost a certainty that teens talk to other teens about getting high on OTC cough and cold medication. As counselors, we need to encourage parents to talk to their children about choosing not to get high on it.

If Sharon Davis, as both a counselor and parent, had recognized the signs of DXM abuse in her son, he might have gotten help sooner. The message we want parents and counselors to hear is that DXM is one of the most popular drugs for teens, and despite it being legal and easy to get, it is not safe when misused. Sharon was unable to prevent all the damage done to her son, but we hope that her story will help parents of children and teens across the country to protect their own sons and daughters.

 

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Emily Weaver is a graduate student in the clinical mental health counseling program at Arkansas State University. She plans to graduate in the spring, become a licensed professional counselor and pursue a career in addictions counseling. Contact her at emily.weaver@smail.astate.edu.

Sharon J. Davis is a professor at Arkansas State University and a certified rehabilitation counselor. Contact her at sharondavis@astate.edu.

David Saarnio is a professor of psychology at Arkansas State University with a specialty in developmental psychology.

 

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Integrating substance dependence and pain management into counseling approaches

By Geri Miller November 5, 2020

In the United Sates, 2000-2010 was labeled the “decade of pain.” In 2011, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education stated that the prevalence of chronic pain in our country exceeded the prevalence of diabetes, heart disease and cancer combined.

Unfortunately, this prevalence of pain has continued, and because of that, counselors need to be aware that substance dependence and pain management may be an issue for their clients — even if it is not a “problem” as presented by clients themselves. Clients may be particularly vulnerable to substance dependence specific to opioids because they (or others in their lives) may view these drugs as the best treatment for pain (i.e., a “quick fix”).

There is a great deal to know about substance dependence and pain management. Because of this, counselors can easily become overwhelmed and hesitate to work with these issues. I am writing this article to help counselors see that they can readily integrate some basic substance dependence and pain management approaches into their current counseling practices and still be practicing within their area of competence.

Because of the prevalence of substance dependence and pain management in the United States, it would serve counselors well to always “wear the lenses” of both of these areas as they assess and treat their clients. However, it is probably most important for counselors who are working with clients specifically on either one of these two areas (substance dependence or pain management) to also intentionally explore the area not presented as a problem so that the potential relationship between the two is examined. For example, when counseling someone who struggles with chronic pain, a counselor would be well advised to also ask about their substance use. The same exploration needs to happen when a client struggles with substance dependence; a counselor should ask about any issues with pain and its management.

While this exploration is important, it is also imperative for counselors to be able to readily fuse these “lenses” into their existing clinical approaches. Five suggestions on the general process of incorporating these two perspectives follow.

First, counselors need to accept the reality that there is a lot to know about substance dependence and pain management and make sure that they work within their area of competence. One method for exploring and addressing these areas with their clients (while still practicing in their area of competence) is to use the “HOW” approach. This acronym encourages counselors to be honest, open and willing to discuss substance dependence and pain management issues with their clients. For example, a counselor can be honest about not knowing much about the client’s experience of pain, be open to being educated about the client’s perspective and be willing to discuss the pain experience with the client.

Second, counselors can anchor their approach in the discussion with respect for and genuineness toward the client. This client-centered approach inherently invites the client’s story of their pain (including the ways they try to handle the pain, such as opiates).

Third, counselors can assess and treat the pain using their typical counseling approaches and continue reassessment throughout the treatment process. Counselors should operate as gatherers of information about the pain and, as appropriate, consult with others (e.g., mentors, supervisors, colleagues, medical professionals) concerning appropriate ways to address the pain.

Fourth, counselors need to be aware of countertransference related to their own and their loved ones’ experiences with pain management and substance dependence. An awareness of their countertransference can enhance counselors’ effectiveness in addressing these overlapping areas.

Finally, counselors need to work within the realistic resource limitations that both they and their clients experience. For example, both counselors and their clients have limitations on the amount of time, energy and money they can invest in learning about and addressing the issues of substance dependence and pain management. Maintaining such a realistic perspective can cultivate more humane and practical counseling interventions that will result in less frustration for both the counselor and client.

An overview of chronic pain

In 2011, as stated previously, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education reported that chronic pain exceeded the combination of diabetes, heart disease and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients are experiencing chronic pain but have not mentioned it or its impact on their lives in session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.

In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information on chronic pain in her book Psychological Treatment for Patients With Chronic Pain. By definition, chronic pain is pain that lasts longer than three months or that extends beyond the expected time it should take to heal. Breakthrough pain is an acute version of chronic pain and centers on days or times when the pain is worse.

Although Darnall called chronic pain a “harm alarm” that tells the person to escape the pain to survive, she said the “riddle of chronic pain” is that it is impossible to escape. This knowledge needs to be fused into the perspective of how the pain experience is affecting our counseling clients in a biopsychosocial manner. This biopsychosocial exploration of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the core suggestions presented in the following section.

Core suggestions

I offer seven core suggestions that counselors can use as a guide in addressing substance dependence and pain management from a biopsychosocial perspective.

1) Work out of a systems perspective. From this perspective, the counselor looks at the systemic interactions that result separately for addiction and pain, as well as their overlap systemically. This means that the counselor is aware of the internal and external contributing factors for both addiction and pain and that the client may have developed an addiction in response to their pain or vice versa. The addiction may have resulted from prescribed medication following surgery, or the pain may have resulted from an accident that occurred while the client was under the influence of alcohol or drugs.

2) Watch for prescribed and nonprescribed substance use. This suggestion means that the counselor obtains information from the client about any prescribed medication of substances (such as medication-assisted treatment) in response to their pain or substance dependence as well as the client’s nonprescribed usage of opiates and marijuana for pain. Such an inclusive gathering of information provides the counselor with a broader view of the client’s treatment responses to managing the pain.

3) Practice “compassionate accountability.” This phrase means that the counselor has compassion for the client and simultaneously holds the client accountable for their behavior. For example, I can have compassion that my client has an addiction resulting from their use of opiates in response to chronic pain that prevents the client from performing activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend’s medicine cabinet.

4) Use firm, direct, honest communication. This is complementary to exercising compassionate accountability because this form of communication avoids enabling behaviors related to both pain management and addiction. No matter what, clients are responsible for the choices they make, and counselors need to be clear with clients about what they see.

5) Consider a harm-reduction perspective. This perspective means that the counselor walks the fine line of not enabling the client’s substance use while at the same time not requiring the client to suddenly commit themselves to abstinence. Instead, the counselor works within the reality of the client’s willingness and ability to change without encouraging the client to remain at the same level of change.

6) Complete assessment and treatment plans for both addiction and pain. This involves the counselor examining both areas in a broad way that includes the client’s fear of the pain returning and their psychological withdrawal from pain medication.

7) Watch for behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively experiencing pain. The client’s pain experience can be processed in the moment, and the resulting information can assist both the assessment and treatment processes.

Assessment

Counselors can use a simple anchoring assessment prompt to elicit each client’s story: “Tell me the story of your pain.”

That open-ended prompt has the power to draw out narratives that clients have perhaps not spoken about previously. These clients may be accustomed to closed questions or scaling questions regarding their pain, but they may never have had anyone ask about and then carefully listen to the actual story of their pain.

This motivational interviewing approach can readily draw out information about the impact of community, culture, family and multicultural factors on the individual’s self-report. For example, the client may talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to reach out for support to address their pain. The counselor could then help the client develop skills to reach out to others who will be supportive of them as they live with their pain, or the counselor might refer the client to a group that discusses pain management approaches.

Another assessment approach is to have clients keep diaries or logs pertaining to their pain, sleep and nutrition. These logs can assist in obtaining information about pain patterns and contributing factors to pain. Such record-keeping also needs to focus on what the client is doing “right” as well as what they are doing “wrong,” in addition to times when the areas of pain, sleep and nutrition are going well for the client. The collection of this information is solution-focused and strength-based. It can become the cornerstone on which healing treatment is built.

The assessment of pain also needs to be considered within the context of addiction. So, although the client has pain, this does not mean that it is necessary for them to use substances to cope with that pain. Neither does the existence of pain prevent the client from being confronted about their addiction as a “stand-alone” diagnosis.

Thus, the message is twofold:

1) The client can learn to live with pain without the use of substances.

2) The client may need to be confronted solely on their use of substances.

Treatment

Treatment for pain can involve various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that seems to best fit the needs of the client, in combination with the resources available related to client income, agency resources and community resources.

Specific therapy approaches can include motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and grief counseling (because when dealing with chronic pain, clients frequently have issues of loss). It is within these forms of therapy where clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g., therapy modalities, specific therapy approaches) and adding the lenses of “pain” and “substance abuse” by asking about information in the assessment process that broadly addresses these areas. Such broad assessment can assist the counselor in knowing whether the treatment of pain and substance use can be readily integrated into treatment or whether a more specific assessment and focused treatment of these areas are required.

Treatments that change the client’s relationship with the pain by focusing on the present (e.g., mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain but work with the knowledge that the intensity of their pain ebbs and flows and learn how to live with that process. They may also find techniques to reduce their pain.

Another treatment approach, described by Kirsten Weir in 2017 in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the diagram above for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.

The three-pronged stool is precariously balanced, which illustrates that self-care is not a static entity but rather one that needs to fluctuate depending on the client and the context. Each leg of the stool (diet, exercise, sleep) is needed to keep the overall stool (self-care) in balance. In other words, each leg has an impact on the others. For example, the experience of pain may negatively affect a client’s sleep, which then inhibits them from exercising and tempts them to eat unhealthy comfort foods. In contrast, a client who gets enough sleep may experience diminished pain, thus encouraging them to exercise and practice healthy eating. Counselors need to remind clients, however, that “pretty good” self-care is good enough; one does not have to practice “perfect” self-care to reap the benefits.

A final treatment approach involves counselors viewing themselves as part of a health management team. Such a team can consist of different health care professionals in which each professional has an important perspective on the unique aspects of the individual client’s pain and pain management. The unique components of the client’s pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical mental health perspective that is needed for a holistic treatment approach.

As part of such a team, counselors familiarize themselves with any prescribed medications that the client is taking for chronic, active disorders. Counselors then play a role in the planned and gradual reduction of medications being taken. Counselors do not need to be experts in pain management or medications to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in serving the welfare of clients.

The counseling perspective offers important contributions to such teams, including a heightened sensitivity for clients’ pain stories and a commitment to advocating for clients. Such a perspective can result in an effective and humane approach to pain management and the use of prescription drugs. Additionally, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.

Conclusions

Clinicians can work effectively with clients by integrating pain management and substance use approaches into their already-existing counseling approaches. Awareness of the prevalence of chronic pain and its potential interaction with substance use can assist counselors during the assessment and treatment process.

Chronic pain and substance use frequently overlap, but they are areas that can easily be missed in terms of their impact on clients’ presenting problems. Simply by integrating the lenses of pain management and substance use into their counseling — asking questions and intervening as necessary — clinicians can offer a more holistic approach to their clients.

The development of these lenses can be enhanced through continuing education, ongoing training and staying informed on current research. There are some excellent resources (see below) that counselors can add to their clinical toolboxes. Counselors who commit to more deeply examining the areas of pain management and substance use can improve their overall treatment effectiveness and, thus, act in the best interests of their clients.

Recommended resources

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Learn more: ACA has produced a series of webinars with Miller on this topic. See more at ACA’s Professional Development Center: https://aca.digitellinc.com/aca/speakers/view/22581

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Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master addiction counselor, licensed psychologist, diplomate in counseling psychology and a professor in the Department of Human Development and Psychological Counseling at Appalachian State University. She has worked in the counseling profession since 1976 and in the addictions field since 1979. She has published and presented research on counseling, and the fifth edition of her book Learning the Language of Addiction Counseling is currently in press. Contact her at millerga@appstate.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Addiction: Paving the way to recovery

By Laurie Meyers October 26, 2020

When the outside world looked at Julie Bates-Maves’ client “James,” it saw a 60-something “junkie” who had wasted 20 years of his life shooting up heroin. But in James’ community of people who used heroin, he was a respected man — an authority figure who could be trusted.

Throughout his two-decade addiction, James had established himself as a safety expert, recounts Bates-Maves, a member of the American Counseling Association. It might seem incongruous to use the word “safety” when speaking about heroin use, but safer injection practices can save lives. James derived great satisfaction from helping his peers reduce their risk of contracting HIV or hepatitis by teaching them never to share needles and demonstrating how to clean their own. He also taught others how to inject without missing the vein.

James’ process of giving up heroin took about a year, but he did well with overcoming the physical addiction, says Bates-Maves, a licensed professional counselor (LPC) whose master’s degree is in rehabilitation counseling with a concentration in alcohol and substance abuse counseling. The hard part was when James was alone and feeling lonely. He struggled with feelings of uselessness, and he knew where he could readily find validation. Among other users, all James had to do was offer to lend his expertise. There was always someone willing to take him up on his offer.

“He had not found respect in virtually any other area of his life,” Bates-Maves says. That meant that in trying to give up heroin, James would also have to leave behind the solitary piece of his world that made him feel worthwhile.

Once Bates-Maves understood that using heroin was tied to James’ sense of self, she realized they needed to examine what it was about the behavior and the attached relationships that provided him with a sense of meaning.

“It was a lot of picking each other’s brains and saying, ‘Let’s try to dissect this,’” she recalls. They set about trying to uncover the actual source of the sense of meaning that James derived from using heroin. “Is it truly tied to the syringe and the bleach and the cotton and the heroin?” she asked him. “Or is it that somebody is listening to you because they think you know something that they don’t?”

Ultimately, James realized that he didn’t actually need the heroin. “I just need someone to look at me and think I’m smart and that I have something to offer,” he told Bates-Maves. So, they worked together to identify another way for James to find a sense of meaning and feel as if he had something to offer others.

Earlier in his life, James had pursued a welding career. For various reasons, he had abandoned that path long ago. But now, he was ready to pick it up again.

With Bates-Maves’ help, James got re-enrolled in a tech program for welding. By going back to school, he acquired a skill set that not many people possess, built new relationships and experienced a sense of validation. He was able to say, “Hey, I’m 62, but I don’t have to check out of the game, and I don’t have to stay stagnant in everything I’ve done,” Bates-Maves explains. “I can add new things to my life, and by adding more to my life, I can add to other people’s lives.”

“So,” she adds, “it became sort of a sense of altruism for him of wanting to give to the world and then to feel good about doing that.”

James had been addicted to heroin for 20 years and recognized that over that time, he had hurt and taken a lot from others, particularly his family. “He had kind of felt like a leech for a long time, and now it was finally time to be able to give that back and repay,” Bates-Maves says.

James was a watershed client for Bates-Maves. His story was the one that changed how she viewed substance abuse counseling. James’ narrative hadn’t been just informational — it had been existential. It made her realize that counselors need to have those types of discussions — about the search for meaning, about the grief and loss that come with substance abuse — with all clients in recovery.

Bates-Maves and the other counseling professionals interviewed for this article say that when therapists center treatment solely on elimination of the substance and everything associated with it from the person’s life — without considering the myriad factors that contribute to use, abuse and the drive to reuse — they are actually hampering clients’ recovery.

The need for grief work in substance abuse therapy

“We oversimplify the picture of addiction,” Bates-Maves says. “We do that as a world broadly, and we definitely do that in the counseling profession sometimes. …We think of it as the erosion of a life — it’s only somebody moving backward, it’s only someone being stuck. And we get stuck in that narrative.”

Counselors often focus on getting clients “unstuck,” which is certainly not without worth, but it is limited, says Bates-Maves, an associate professor of clinical mental health at the University of Wisconsin-Stout. “I’ve worked with many clients who … loved being stuck [in addiction],” she says. They loved the feeling of being someone else, the ability to lose sight of negative things, the ability to create an optional numbness.

Addiction sets the stage for a lot of destruction in people’s lives, but it can also serve as a kind of desperate sustenance for users who see no other way to cope with life, Bates-Maves says. The bald truth is that substance abuse also adds things to life, and that’s something counselors don’t talk about enough, she asserts. Counseling is a profession that focuses on concepts such as identity and a person’s sense of meaning, yet counselors often neglect to explore how these concepts tie in to addiction — what clients are actually getting from their substance abuse, what makes it attractive or useful to them, she says.

When presenting on the role that grief and loss play in addiction, Bates-Maves has frequently heard from audience members that the clinics in which they work have told them not to talk about the “good stuff” that substance use brings. She says the usual company line is, “You can’t have them celebrate the high or tell those so-called glory war stories. That’s encouraging their desire to use.”

“We’re so blinded by this fear of people going back to use,” Bates-Maves says. “What if the glory days were the only time people felt powerful, or what if when they’re high, it’s the only time they don’t feel intense [emotional or physical] pain? What if it’s the only time they feel confident enough to engage with another human? … Those are central treatment issues, and they can come out of the quote-unquote ‘positive experiences’ in addiction. There’s a lot to let go of when you’re trying to get to recovery. There’s a tremendous amount of loss, and [we’ve] somehow largely missed that as a field.”

Bates-Maves feels so strongly about the necessity of counselors having these conversations with clients as part of the recovery process that she wrote a book, Grief and Addiction: Considering Loss in the Recovery Process, which was released at the end of September.

“Addiction … ravages your life,” Bates-Maves says. “Nobody likes that.” Even so, she continues, counselors need to encourage clients to think about the things they risk losing when they determine to confront their addiction.

“Even if they’re good losses — things you want to go away — it’s still a massive change that you’re undertaking,” she tells clients. “You deserve to feel sad and frustrated and sorrowful … and relieved.”

Even though the changes people go through in recovery need to happen, clients deserve to know that it’s OK for them to miss the things they leave behind. “You can miss it forever and still change,” Bates-Maves says emphatically.

“When we start to try and shove people forward to recovery without looking at the rearview mirror at all, we’re going to miss the things that will chase them down later,” she explains.

Bates-Maves believes Kenneth Doka’s model of disenfranchised grief perfectly explicates the losses sustained by people struggling with addiction. In the recovery process, these clients typically must abandon coping methods and even relationships that are unhealthy. As such, these things are often deemed “unworthy” of grieving over.

Similarly, many clients in recovery have lost friends to stigmatized deaths such as overdose, suicide, hepatitis and AIDS. Other clients may have chosen abortion or had a miscarriage because of their addiction. Once again, these individuals can be made to feel that they aren’t allowed to grieve those losses, Bates-Maves says. In particular, family members — and the courts — tend to convey the message, “You dug your own hole.”

But everyone has losses from predicaments that are primarily self-created, Bates-Maves argues. “I have this grief all the time where I’m the one who caused the problem, but I’m still really mad that I have it,” she says.

Emotions that are denied usually just fester and show up in other ways, Bates-Maves says. “Just let people” — including those struggling with addiction — “be angry. Let them be sad. Just because we’re the creators of our own misery does not mean we don’t deserve to be miserable about it,” she says.

Counselors can offer clients support as they learn to acknowledge that their current reality — whatever stage of addiction or recovery they’re in — is incredibly tricky and comes with myriad, and often confusing, emotions, Bates-Maves says. What counselors shouldn’t do is tell clients that what they’re feeling is wrong or try to “cheerlead” them into a different emotional state, she continues.

People sometimes picture coping as having overcome a difficulty so that it no longer has any emotional effect on them, Bates-Maves says. “I think it’s really important for all of us to remember that’s not what coping is. Coping isn’t getting over something. … It’s living with something. It’s getting through it as you’re in it.”

“My job as a counselor is not to make the pain go away, because I can’t,” Bates-Maves continues. “It’s not to force the transformation of pain. That’s a hope, but sometimes that can take longer than my relationship with [the client].”

So, what is the other side of grief? What is the goal of grief work? Bates-Maves describes it as learning to walk with and carry your pain in a way that doesn’t sink you. “You want the pain to be manageable so that you can live life with it there,” she says.

Bates-Maves recommends a variety of methods to help clients, including those walking through addiction and recovery, with their grief and pain. One method is containment — the idea of compartmentalizing the pain and building psychological space for it. She says this is particularly useful for pain attached to situations that are unlikely to be resolved anytime soon. Some clients make actual physical boxes, write down their thoughts, feelings or whatever it is that is causing them distress, and lock it up, but the container need not be literal, Bates-Maves explains.

The intent of the exercise is not to lock the person’s pain up forever, but rather to put it aside so that the person can carry on with the other parts of their life. This acknowledges the reality that even when people are hurting badly, the demands of living go on. When a client has the time or desire, they can open the container, sit with the pain and feel whatever they feel. Being able to set aside the pain temporarily allows clients to care for their children, drive to work or even just relax by watching TV or listening to music without being confronted by constant intrusive thoughts, Bates-Maves says. Journaling is another way that clients can create a space outside of their own heads for their emotions, she adds.

In contrast, radical acceptance, a method that is the polar opposite of locking one’s thoughts away, can be very effective for some clients. “It’s this idea that we cannot always change things and we need to accept and acknowledge it and keep moving,” Bates-Maves says. With radical acceptance, clients learn that their grief and pain are valid but that they can feel those emotions and still keep moving alongside them.

Bates-Maves has also had clients who experienced intense and disturbing dreams about their grief. She would teach them “directed dreaming.” Clients would take five to 15 minutes before going to bed to create detailed mental pictures in their minds of what they wanted to dream about. With practice, people can learn to direct their dreams, Bates-Maves says.

For clients who frequently feel overwhelmed, Bates-Maves recommends belly breathing. She explains that teaching people to breathe more efficiently can reduce panicked breathing, which helps take the body from a state of distress to one of relaxation, or at least closer to it.

She sometimes helps clients transform their pain by learning to reframe how they view their losses. Certain clients realize that they will never feel differently about parts of their past but that they are OK with that. Some clients work through their pain by seeking connection with others. And some clients decide that they need to spend more time with themselves rather than with others, hoping to learn who they are without addiction.

Attachment, trauma and addiction

Many people with addiction have been primed to seek solace in substances or processes because of a history of trauma and a lack of healthy attachments, says ACA member Oliver J. Morgan, who has written numerous books on substance abuse and addiction. Caring relationships can help mitigate the effect of trauma in a child’s life, whereas a lack of those connections is traumatic in itself. Feeling cared for helps build healthy neural connections such as a fully functional stress response and the reward, reinforcement and motivation systems that contribute to emotional coping skills, he explains.

When someone finds it difficult to cope with stressors such as the lasting pain of trauma, dysfunctional relationships, loneliness or the everyday disappointments and frustration of life, they may turn to addictive substances or behaviors, says Morgan, a licensed marriage and family therapist who has been clean and sober for over 30 years but once was addicted to alcohol.

Over time, chronic use and abuse of substances or processes oversensitize areas of the brain related to dopamine so that they are easily triggered, he says. The brain then connects those areas to memory and environmental cues that themselves create desire. In other words, addiction causes the brain to react to cues that a client may not even know exist, Morgan says, creating what neurobiologists call “pulses of craving.”

“The brain organizes reward around memories so that we remember to repeat [the action],” says Morgan, a master addiction counselor. “It’s how we learn and how we fall in love.” A particular song on the radio, specific places or people, or even certain scents can serve as triggers.

That’s why he views all addiction counseling as relapse prevention. “From the beginning, you need to prepare people for the possibility, if not probability, of relapse,” says Morgan, a professor of counseling and human services at the University of Scranton.

He uses psychoeducation to explain the neurobiology underlying addiction and relapse — not just to clients, but to their families if they are willing to listen. Morgan believes this is essential to preventing a common scenario: A client relapses and their family says, “He told me he was going to stop and he didn’t. He lied to me.”

It’s not quite that simple, Morgan says. He explains to families that their loved ones mean it when they say they’re going to stop using, but they’re not anticipating that their brains are going to react to these cues. So, a relapse doesn’t mean that the client isn’t committed to recovery, Morgan says. The support of loved ones helps clients remain dedicated to the recovery process and keep believing that they can achieve it — even if they are momentarily derailed by a relapse.

Morgan, a member of the International Association of Addictions and Offender Counselors, a division of ACA, believes that relationships are the ultimate buffer against addiction. From the start of the recovery process, he helps clients begin forging new relationships with people who are clean and sober. They might develop these connections by finding sponsors or reaching out to strangers at Alcoholics Anonymous (AA), Narcotics Anonymous (NA) or other recovery group meetings and virtual gatherings.

Morgan also gives clients a laminated card with steps to take if they feel the urge to use. This can function as a kind of crisis plan or serve as a reminder to clients that they have tools to help prevent relapse. The first step is to acknowledge their urge but to remind themselves that it is just a feeling, not something that they have to act on.

Next, Morgan wants clients to reach out to someone whom they trust and can talk to. “The best way to deal with stress is to buffer with a relationship,” he says. The person or people clients reach out to could be a sponsor, recovery group members or Morgan himself. This gives clients a way to share the burden by verbalizing their feelings and getting some advice. If none of this works, he tells clients to call him (assuming he wasn’t the person they reached out to initially).

Because the urge to use is triggered by external and internal cues that clients may not even be aware of, Morgan urges counselors to walk these clients through their past. He asks clients to think about times when they were using or wanted to use. What was happening in their lives at the time? What were their favorite songs? The broader the exploration of everything in their lives, the more likely it is that potential relapse triggers can be identified.

“Sometimes,” Morgan says, “you have to wait for them to come into session and say, ‘I really wanted to use’ [to discover their triggers]. That’s why it’s important to let them have access [to you] when it happens [between sessions] so that you can walk them through it. ‘Where were you? What happened? Who was with you?’”

Once the client and counselor have identified triggering situations, they can work together to come up with better ways to handle them. In his own life as someone who was addicted to alcohol, Morgan uses humor. “I make a joke out of it and talk about it widely,” he says.

When Carol Sloan Goodall, a licensed clinical addictions specialist, led group work at a local recovery center, she frequently had clients form smaller circles to identify three external, three internal and three sensory triggers. Group members also had to come up with three ways to cope with each trigger.

“I was often pleasantly surprised to see how many different realistic coping skills they created and excited to see the clients impressed and motivated by these ideas,” says Goodall, a licensed clinical mental health counselor in private practice in Charlotte, North Carolina.

Common external triggers involved people, places and things. Internal triggers usually involved emotions but sometimes also included cravings, chronic pain or illness. Sensory triggers were just that — input from the five senses, such as smells, tastes and sounds.

The coping skills that clients came up with were varied. One client described avoiding temptation by changing their route upon realizing that their drug dealer lived on a particular street. Another client felt like their home was a trigger, so they rearranged the furniture and changed the color of the accessories to make it appear new and different.

“One client said he carried a dryer sheet in his pocket and sniffed it when triggered by scents reminding him of drug use,” Goodall recalls. “Another client stated that the perfume cards you spray in department stores served the same purpose.”

Goodall also suggested that when confronted by triggers, clients could distract themselves with sensations such as snapping a rubber band on their wrists or holding an ice cube.

Morgan is a believer that practicing mindfulness can help clients identify and even anticipate triggers. He teaches clients to sit down and find a place on which to focus — a spot on the wall, a beam of sunlight, a candle. Then he instructs them to just “be” in that moment and observe what is happening around them in the here and now, to cultivate awareness and to notice if the urge to use is creeping up. He also finds this mindfulness practice helpful for coping with anxiety and creating a sense of calm by just being in the moment, letting one’s thoughts and emotions float by, and then letting them go.

The necessity of reducing in-person meetings during the pandemic has in some ways made it easier for those in recovery to get support. Groups such as AA, NA and other recovery organizations swiftly moved their meetings to digital platforms. People can access virtual meetings or keep in touch with other group members through social media, email or phone. Counselor clinicians have also had to become more comfortable with virtual counseling. Morgan sees this as a positive because he thinks not having to show up in person to access resources is easier for many people who are seeking help with substance abuse. It’s less uncomfortable for these clients, Morgan says, because they don’t quite have to put themselves out there completely.

Going from prison to the outside world

Julia Thielen, an LPC located in South Dakota, works at an intensive outpatient facility with a particularly challenging substance abuse population: clients living in a post-prison transitional facility after being incarcerated for as long as 10 to 15 years.

These clients are not only working toward recovery, but also coping with trauma and trying to navigate a world that they don’t recognize or understand, Thielen notes. They have records, have spent years without employment, are often estranged from their families, have often lost friends to causes such as overdose, and struggle to form a sense of identity. Life has generally moved on without them. The things these clients may have once wanted — steady jobs, families, a house of their own — now feel largely out of reach to them, Thielen says.

Those around these clients often want to sugarcoat their circumstances and make them feel better, but what they really need, Thielen says, is someone to hear them out and help them set realistic goals. “Yes, you are past 30, so having a house before then is not going to happen. But is it possible to achieve that by 40?” she asks them.

For clients who have spent a particularly long time in prison, just getting a job is challenging, Thielen says. They lack a history of employment and have to disclose that they spent time in prison. They need help finding any form of employment just to reestablish a work history so that further down the line, future employers at potentially more attractive jobs might be able to see them as responsible and hard-working, she explains.

In addition to teaching these clients emotional self-regulation skills such as deep breathing, Thielen and her colleagues instruct them in basic life skills. Many of these individuals spent their adolescence and young adulthood in prison, so in essence, they have skipped a developmental stage, she says.

Thielen’s clients regularly talk about the challenges of finding healthy friends and activities. “One of the big things they are lacking is any kind of support or stability in their lives,” she says. Getting these clients involved with AA, NA or another recovery group is one way to help them establish friendships with people who don’t use or who are also in recovery.

Many of Thielen’s clients don’t know what healthy friendships look like, so she spends a significant amount of time helping them identify red flags from their past relationships, such as behaviors that led them toward addiction or contributed to them staying addicted. Often, Thielen says, these friends from clients’ former lives would call in sick for the client when they were hungover, pay their fines for misbehavior or help them come up with excuses for their probation officer.

Another piece of the puzzle is to help these clients articulate what values they would like potential friends to possess. Often, the easiest way to do this, Thielen says, is to ask them what values and beliefs they would like to instill in their own children and to look for those same characteristics and qualities in others when forming new friendships.

But most of Thielen’s clients still have strong ties to the people they previously used with. These aren’t “healthy” friendships, but many of these clients have no one else in their lives upon being released from prison. In many cases, their families and any friends they had who weren’t fellow users have given up on them long ago. From the perspective of some clients, the people who were their fellow users and have maintained contact have “been there” for them, and the clients want to reciprocate. But spending time with these friends — who may not be interested in stopping their own substance use — is the most common road back to addiction and, often, reincarceration.

Some clients can have the hard conversations and cut ties with the people who are linked to their past substance abuse and prison time, Thielen says. But that’s almost an impossible ask until they have formed new relationships. That is why getting them into some type of new community such as a self-help group, addiction recovery group or church group is critical, she says.

Another challenge is that although a transitional facility can offer support and shelter to those who have recently been released, the environment isn’t very conducive to learning responsibility, Thielen says. These clients learned to follow a particular set of rules in prison, and now they learn to follow another set of rules in the transitional facility, but they aren’t necessarily learning how to set a budget, how to cook a meal or even how to buy groceries for themselves.

Thielen and her colleagues attempt to set clients up with case managers and life skills coaches, but she acknowledges that some individuals are very resistant to this kind of instruction.

Prevention and intervention

Counselors do have opportunities to intervene — before addiction, before prison, before a life goes off the rails. Morgan notes that while the focus is typically on those who are physically addicted to substances, almost three times as many people are problem users. And it is these individuals whom counselors are most likely to see, he says.

Morgan asserts that addiction professionals don’t necessarily know how to deal with those individuals who are problematic users but have not reached the threshold for addiction. Recovery centers aren’t suitable for these individuals because they aren’t physically addicted, he says.

But professional counselors can help clients explore and recognize their problem use through exposure to motivational interviewing and the stages of change, Morgan says. Often, these clients have ended up in the counselor’s office because they’ve had trouble at work, at school, with their family or other relationships, or elsewhere. They may flatly deny any suggestion of “problem use,” but counselors can suggest exploring what is going on in these clients’ lives.

“If they’re willing, that already puts them into precontemplation,” Morgan says. Counselors can take that recognition that something’s not quite right and say, “Let’s look at what change looks like,” he suggests. “Let’s stop drinking, drink less or drink less harmfully.”

“We have to pay attention to moments of opportunity,” he stresses. “Someone gets pulled over for a DUI — that’s a moment of opportunity.” If someone is overdrinking and prone to accidents around the home, every visit to the emergency room is an opportunity, Morgan continues. Some hospitals are already using motivational interviewing for brief interventions in the ER, and the success rates have been impressive, he says.

The problem is that for too long, the message has been that when people with substance abuse problems are ready, they will seek help, Morgan says. But most of the time, they’re not going to come in on their own, he asserts.

“We have to raise the bar,” Morgan concludes.

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

International Association of Addiction and Offender Counselors (iaaocounselors.org)

IAAOC, a division of ACA, is an organization of professional substance abuse/addictions counselors, corrections counselors, students and counselor educators concerned with improving the lives of individuals exhibiting addictive or criminal behaviors.

Counseling Today (ct.counseling.org)

Books (imis.counseling.org/store)

  • A Concise Guide to Opioid Addiction for Counselors by Kelvin Alderson and Samuel T. Gladding
  • A Contemporary Approach to Substance Use Disorders and Addiction Counseling, second edition, by Ford Brooks and Bill McHenry
  • Addiction in the Family: What Every Counselor Needs to Know by Virginia A. Kelly
  • Treatment Strategies for Substance and Process Addictions by Robert L. Smith
  • Introduction to Crisis and Trauma Counseling edited by Thelma Duffey and Shane Haberstroh
  • Coping Skills for a Stressful World: A Workbook for Counselors and Clients by Michelle Muratori and Robert Haynes

Webinars and article for continuing professional development (aca.digitellinc.com/aca)

  • “Opiate Addiction and Chronic Pain: Overview of Counseling Approaches” with Geri Miller
  • “Opiate Addiction and Chronic Pain: Ethical Practices for Counseling Clients Who Live With Chronic Pain” with Geri Miller
  • “Opiate Addiction and Chronic Pain: Hope, Resilience and Self-Care Strategies for Counselors and Clients” with Geri Miller
  • “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl
  • “Developmental Approaches in Treating Addiction” by Ford Brooks and Bill McHenry
  • “Complicated Grief: An Evolving Theoretical Landscape” by Laurie A. Burke, A. Elizabeth Crunk and E.H. Mike Robinson III
  • “Screening, Brief Intervention, and Referral to Treatment (SBIRT) for Substance Misuse” with Amy E. Williams and Kristin Bruns

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Substance use disorders and addiction
  • Grief and loss

 

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Laurie Meyers is a senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

A climbable mountain: Quitting smoking and managing mental health

By Bethany Bray August 10, 2020

For people with a preexisting mental health condition, quitting smoking can seem like climbing two mountains at once.

Managing a mental health condition is a daily — sometimes moment-by-moment — challenge, and smoking is often used as a coping mechanism. Understandably, people with mental health conditions who smoke often fear that taking away that source of comfort could send them into a tailspin.

“That was the way I always seemed to manage my stress: Sit down, light a cigarette, and it would make my brain think, ‘It’s going to be OK.’ But in reality, it’s not,” says Rebecca M.* a Florida resident and participant in the Centers for Disease Control and Prevention (CDC)’s Tips from Former Smokers campaign who lives with depression.

Rebecca smoked her last cigarette in 2010. She quit smoking for good — and found balance in her life — with the support of a professional counselor. In hindsight, smoking only made her depression worse, Rebecca acknowledges.

For many people, mental health and smoking go hand-in-hand — you can’t fix one without addressing the other, she asserts.

“Wanting to be healthy, mentally, while smoking is impossible. After I quit, I was able to look at the world with a completely different mindset,” Rebecca says. “Smoking affects every aspect of your life — family relationships, work life, home life. It’s just a cloud. … When I see people who are struggling with mental health [while smoking], I have deep compassion for them. You want so desperately to get better, but with smoking, it’s like taking two steps forward and two steps back.”

In the family

Rebecca says she was “born into a family of smokers.” Growing up, all of her friends and family smoked, so it seemed natural for her to start smoking as a teenager.

She quit smoking for the first time in 2002. However, she started smoking again seven months later as she was going through a divorce and struggling with intense emotions and stress, she recalls.

Throughout this period, she met with several different counselors to help her manage her depression. She had an “aha!” moment in 2009 when her first grandchild was born; she knew then she wanted to quit smoking for good.

“When my oldest grandson was born, it made me stop and think about life in a different perspective. At that time, I reached out to find another counselor, to learn from past mistakes and learn a new way of life,” says Rebecca.

After smoking for more than three decades, she quit fully in 2010, roughly one year after setting the intention, seeking counseling, and going through “some intense self-reflection,” she says. “I was thinking about how I’m a grandmother now, and where do I want to be [in life]? I had a desperate desire to live a healthy lifestyle, and what can I do to get there?”

“Counseling gave me a sounding board, someone I could trust who could give me trusted answers,” Rebecca says.

Since quitting, she says, she has had to examine some friendships with close friends and even family members who continue to smoke. “If they’re not healthy for you, supportive of your healthy lifestyle, it’s important to make those changes as well,” she says. “It was a perspective shift: It’s the difference between being born into a life that you don’t get to choose and choosing the life that you want to live.”

The climb

Professional counselors can help clients meet life’s challenges with an approach based on leveraging the client’s existing strengths. For Rebecca, this included her intention to be a healthy example to her grandson. Practitioners have an arsenal of tools that can help clients make life changes and reach their goals, including smoking cessation.

Rebecca’s counselor helped her establish a self-care routine that includes exercise (she now runs regularly) and meditation. She has come to realize that she needed to exchange one unhealthy behavior, smoking, with a healthy behavior, exercise.

“Nothing will go well unless you take care of yourself first. Counseling taught me how to take care of myself first,” she says.

“[Quitting successfully] is about teaching people about the tools they need. When they are faced with a situation that may make them uncomfortable, or trigger a panic attack or need for a cigarette, they have to have [coping] tools ready and available. For me, it’s been exercise, staying grounded, and focusing on what I can control. I’m [continuing to] educate myself and learn as much as I can so that I can give myself the best self-care I can,” she says.

Most importantly, Rebecca’s counselor helped her accept that her depression, her tobacco dependency, and “all of this was not my fault,” she says.

“I don’t think I could have quit without counseling. I didn’t have the knowledge to do it on my own,” says Rebecca, who turned 63 this summer. “It’s essential to get someone [a mental health professional] who can help you walk this path to healthy living. It’s a path, a journey. It’s one step at a time, one day at a time, sometimes one moment at a time, but it’s empowering. It’s doable, and it feels amazing.”

Rebecca M. has exchanged one unhealthy behavior, smoking, with a healthy behavior, exercise. After smoking for more than three decades, she quit fully in 2010. Photo courtesy of the CDC’s Tips from Former Smokers campaign.

Ten years after quitting smoking, Rebecca’s mental health is good, but she acknowledges that she has to work at it every day. In addition to exercising regularly, she meditates often and tries to approach each day with an attitude of gratefulness, especially for things like a walk on the beach or video chats with her grandsons.

“I’m grateful for every one of those little moments I get,” she says. “It feels wonderful to climb that mountain. … It’s so empowering to be able to overcome tobacco use. There is a lot of life left [after cigarettes], even if you think there’s not.”

Counselors as allies

Professional counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification. Instead of focusing on the health consequences of smoking — as a medical professional might — counselors can instead help clients focus on why they want to quit and how they can leverage their own strength to achieve that goal.

Practitioners also use a holistic perspective to help clients. For example, if a client turns to smoking in social situations because of anxiety, a counselor would help the client address the root cause, finding ways to cope with social anxiety. Similarly, if a client smokes to escape the negative thoughts that can be a constant companion of anxiety, depression, obsessive-compulsive disorder or other mental health conditions, a counselor can equip the individual with techniques to quiet their inner critic.

Read more about the many ways that professional counselor clinicians can support clients on their journeys in the Counseling Today article “What counselors can do to help clients stop smoking.”

In addition to counseling, Rebecca encourages people to use the plethora of tobacco cessation resources offered by the CDC.

“It’s OK to seek help,” she urges. “[Counselors and other professionals] want to see you succeed. You have it in you to succeed. That success is within you; you just have to learn to be kind to yourself and be loving to yourself. That, more than anything, was what I had to learn: to give myself the love that I give others.”

 

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For support to quit smoking, including free coaching, a free quit plan, educational materials and referrals to local resources, call 1-800-QUIT-NOW (1-800-784-8669).

 

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*Rebecca M.’s last name has been omitted for privacy reasons.

 

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Resources

From Counseling Today: “What counselors can do to help clients stop smoking

Find a professional counselor in your local area through the link here: counseling.org/aca-community/learn-about-counseling/what-is-counseling/find-a-counselor

CDC’s Tips from Former Smokers campaign: cdc.gov/ tips

Rebecca M’s page: cdc.gov/tobacco/campaign/tips/stories/rebecca.html

CDC page on quitting smoking: cdc.gov/quit

Additional CDC resources on addressing tobacco use in individuals with behavioral health conditions:

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.